MEDICARE: DR. KEITH E ISENBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	R3C83	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23898	OTHER		MO-BLUE SHIELD

General Provider Information

NPI Number	:	1770501231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH E ISENBERG MD

Provider Business Mailing Address
First Line	:	1831 CHESTNUT ST
Second Line	:	M/S: MOM904-S350
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2225
Country	:	US
Telephone Number	:	314-923-8647
Fax Number	:	314-923-4857

Provider Business Practice Location Address
First Line	:	1831 CHESTNUT ST
Second Line	:	M/S: MOM904-S350
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-2225
Country	:	US
Telephone Number	:	314-923-8647
Fax Number	:	314-923-4857

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	06/17/2008

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